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Counseling Referral
A student, a parent, a teacher, the principal, or any staff member may complete the form if requesting a student to speak with Mrs. Rinkel.
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
First Name of Student to meet in session.
*
Your answer
Last Name of Student to meet in session.
*
Your answer
Name of Teacher Requesting or if Student is making the request indicate Student Activity Period teacher.
*
Last name only. example: Rinkel or state "I'm in Mrs. Jo Meyer's Room
Your answer
What grade is student needing to see counselor? Click on parent if requesting a parent meeting.
*
Choose
9th
10th
11th
12th
FCCC
Parent
Referral Source
*
parent
teacher
principal
staff member
Student
Required
Is this referral related to school performance?
School performance is not a concern.
Academic progress
Organizational skills
Peer relations
Authority figure relationships
Inattention
New students
Other:
Is this referral related to home?
Home situation does not appear to be a concern.
Conflict
Sibling relationships
Seperation/divorce
Death
Other
Is this referral related to emotional needs?
Emotional needs do not appear to be a concern.
Sadness
Nervousness
Anger
Fearful
Mood Swings
None of the above
I would like you to:
*
Observe this student in my room.
Discuss this student with me.
Talk with me or the requested student today.
Talk with me or requested student this week.
Talk with me or the requested student when you become available.
Required
Provide any additional information that my be helpful to me when meeting.
Your answer
Rank the situation on a scale 1-10
A small concern
1
2
3
4
5
6
7
8
9
10
An emergency situation
Clear selection
Select times that would be ideal for counselor to meet with this student/parent.
Select more than one time if necessary
Between 8:30-9:00
Between 9:00-9:30
Between 9:30-10:00
Between 10:00-10:30
Between 10:30-11:00
Between 11:00-11:30
Between 11:30-12:00
Between 1:00-1:30
Between 1:30-2:00
Between 2:00-2:30
Between 2:30-3:00
Anytime that works best for the counselor
After school hours
Submit
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